Public Views on Medicaid Work Requirements and Mandatory Premiums in Kentucky

Key Points Question How do adult residents of Kentucky perceive general and specific policies regarding Medicaid work requirements and premiums, and do views differ by Medicaid enrollment? Findings This survey study found that, despite general support for Medicaid work requirements, most respondents did not support terminating Medicaid benefits or setting quotas requiring 20 or more weekly hours, and fewer than half of respondents supported Medicaid premiums or terminating benefits to penalize nonpayment. Beliefs differed between Medicaid enrollees and nonenrollees. Meaning This study suggests that public support may differ for general policy ideas vs specific policy elements and for people who are directly affected by a proposed policy change.


Introduction
Medicaid is vital to the US safety net, and it was a central means of federal support during the COVID-19 pandemic.As the national public health emergency concluded, more than 90 million people were enrolled in Medicaid and the Children's Health Insurance Program. 1 But as the public health emergency unwinds, political pressure to reduce Medicaid costs has escalated.Recent proposals-including a newly effective state waiver 2 and debt negotiation proposals-have supported work requirements and premiums for adult Medicaid beneficiaries, particularly those eligible under the Patient Protection and Affordable Care Act (ACA) expansion. 3peated calls for Medicaid work requirements and premiums in state waivers, block grant proposals, and legislation suggest that these issues will persist. 4Work requirements were central to the Trump administration's approach to public benefits 5 ; the Centers for Medicare & Medicaid Services (CMS) approved work requirement waivers for 19 states during the Trump administration, asserting that they would increase health and reduce poverty. 68][9] In Arkansas-the only state that implemented work requirements with exclusion penalties during the Trump administration-nearly 18 000 people lost Medicaid, but employment and work hours were unchanged. 7In New Hampshire, which did not enforce penalties, 17 000 people (67% of eligible adults) fell short of required work hours in the first month. 10ate Medicaid work requirements in Arkansas, 11 New Hampshire, 12 Kentucky, 13 and Michigan 14 were eventually struck down by federal courts, which found that CMS had failed to consider the projected coverage losses among beneficiaries.Other waivers were rescinded by the Biden administration, but a federal court reversed the cancellation of Georgia's "Pathways to Coverage" program, which implemented work requirements and premiums this year. 15Rather than implementing a full ACA expansion, Georgia offers Medicaid to only "able-bodied" adults with eligible incomes who document 80 hours of qualifying activities per month. 16,17Arkansas has proposed a new waiver that offers more attractive Medicaid benefits to those who meet work engagement expectations. 18,19deral work requirement proposals also continue, such as the Limit, Save, Grow Act of 2023 passed by the House of Representatives.This legislation would have omitted federal matching payments and allowed states to disenroll adult beneficiaries without 80 monthly hours of work or volunteering in 3 or more months. 20These initiatives echo work requirements in the Supplemental Nutrition Assistance Program and Temporary Assistance to Needy Families, which have been associated with losses of benefits that equal or exceed gains in earnings. 21,22ivers requiring Medicaid beneficiaries to pay monthly premiums are ongoing.Georgia's program, for example, requires premiums for new enrollees with incomes above 50% of the federal poverty level 16 ; as of 2021, 8 other states had permission to charge monthly fees. 23Program evaluations have demonstrated that premiums reduce program enrollment, 24 and the Biden administration has made efforts to rescind or limit waivers that enforce premiums.[27][28] General policy views, however, do not provide feedback about specific program features.

Methods
We conducted an anonymous survey of Kentucky adults via the telephone and internet.We included were ineligible.Response rates were 3.6% for landline and 5.2% for cell phone participants, using AAPOR definitions.Sampling for both types of telephone line divided the 120 Kentucky counties into 8 different strata based on the percentage of households with incomes below 138% of the federal poverty level.We oversampled from low-income strata to ensure sufficient sampling of Medicaideligible participants.We also oversampled cell phones flagged as prepaid and compensated these participants $10 for their minutes.SSRS interviewers conducted cell phone interviews with the person who answered, and landline interviews with the youngest adult home at the time of the call.
All interviewers confirmed that the person was an adult and in a safe location before administering the survey.
The internet panel recruited 602 respondents from an invited, nonprobability panel of adult Kentucky residents maintained by Dynata.Sampling used the same county-based method as above.
Respondents were excluded if they skipped 20% or more of the questions asked of all participants, failed at least 2 of 3 attention-check questions, or finished in less than 30% of the median survey time.Dynata compensated online respondents at standard rates.We assessed participants' agreement with Medicaid policy positions, using Likert scales from 1 (strongly disagree) to 7 (strongly agree).We classified 5, 6, or 7 as agree; 1, 2, or 3 as disagree; and 4 as neither agree nor disagree.The order of attitudinal questions was randomized, and questions drew on prior studies of Medicaid stigma. 32,33This study reports results for participants overall and by selfreported current enrollment in Medicaid.We further disaggregated each group by self-reported employment status and by political affiliation.For each pairwise group comparison, we used Pearson χ 2 tests with the Rao and Scott second-order correction to compare distributions of beliefs (agree, neither, or disagree); this approach accounts for our sampling and weighting methods.All P values were from 2-sided tests and results were deemed statistically significant at P < .05.

Results
Results in text and in Among Medicaid enrollees (Table 3), the distribution of support for premiums and for terminating nonpayers' benefits did not differ by employment status or political affiliation.Among Medicaid nonenrollees (Table 4), beliefs about premiums did not differ by employment status, but again differed by political ideology; Democratic nonenrollees were less likely to support and more likely to oppose premiums and termination of benefits for nonpayment than Republican nonenrollees.
Among Medicaid enrollees (Table 3), Democratic enrollees were more likely than Republican enrollees to agree that people are on Medicaid due to circumstances beyond their control.Beliefs e Response categories for sexual orientation included lesbian or gay, straight (this term was used instead of heterosexual), bisexual, and something else.
f Participants could select multiple sources of current insurance coverage, so totals across all categories exceed 100%.The "uninsured" response category includes participants who answered "no," "declined," "don't know," or "refused" to every source of health insurance named.
g Among respondents who indicated they were employed (510 participants in full sample; 345 people not enrolled in Medicaid; 155 people enrolled in Medicaid).Among Medicaid nonenrollees (Table 4), political affiliation (but not employment status) was associated with significantly different beliefs about Medicaid beneficiaries.Republican nonenrollees were more likely to endorse the beliefs that Medicaid "should only be for people who cannot work" and that the program makes people "less interested in working"; they were less likely to endorse the ideas that people are on Medicaid due to circumstances beyond their control and that society has a responsibility to help them.Republican nonenrollees also believed that larger proportions of people "receive but do not need" Medicaid benefits.

Discussion
In Kentucky, a state that had federal approval to implement work requirements and premiums for Medicaid, most participants expressed general agreement with work requirements for Medicaid enrollees who are able to volunteer or work.But only a minority of participants-among the full sample, those enrolled, and those not Medicaid-supported the policy features that had been approved in their state, including termination of benefits for noncompliance and hourly work quotas of 20 hours or more.Among Medicaid enrollees, support was lower among people who were unemployed compared with those who were employed; among nonenrollees, support was lower among Democratic participants than among Republican particpants.Republican nonenrollees were the only subgroup to report majority support for terminating benefits for people who do not meet work or volunteer quotas.
Although monthly premiums have a longer history in Medicaid, they were uniformly less popular than work requirements across all groups.Support for mandatory premiums was lower among enrollees than nonenrollees, but these 2 subgroups reported uniform opposition to terminating benefits due to premium nonpayment.Among nonenrollees, Democratic participants reported less support for mandatory premiums and exclusion penalties than Republican participants, but no subgroup reported majority support for these policy components.
General views of Medicaid enrollees and purposes differed by Medicaid enrollment and political affiliation.Enrollees and Democratic participants reported more supportive views of Medicaid participants, and they estimated that lower percentages of enrollees "receive but do not need" Medicaid benefits, compared with nonenrollees and Republican participants.For the most part, employment status was not associated with differences in views about Medicaid's beneficiaries and purposes, save for one finding: employed enrollees were more likely to endorse the belief that the Public preferences should influence state and federal policymakers considering benefits program design.5][36][37][38][39][40][41][42][43] But even people who do not currently depend on Medicaid for health care access have a stake in whether elected politicians and regulators are acting with democratic legitimacy-that is, whether they are responding to voters' priorities.Policies lacking popular backing are susceptible to litigation and political upheaval, as well as threats to program participation and compliance.Lawmakers' responsiveness to public priorities can also affect participation in the political process.5][46] Policymaking processes sometimes build in avenues for public input, such as notice-and-comment periods or town halls.But although these are important sources of information, participants in these venues may not be representative of the populations affected by policy change. 47,48Public comment periods also occur after extensive policy development and thus may be limited in their capacity to achieve change. 49Systematic and representative investigation of public views is an important complement to public comment procedures.
Responsiveness to the public is an important policy priority, but it is not the only consideration.
Legislators and regulators must also consider governmental resources, urgency, feasibility, sustainability, predicted effectiveness, political ideology, and concerns such as fairness and equity.
Deferring to a voting majority can also be associated with disadvantages for members of smaller or politically marginalized groups (eg, members of racial and ethnic minority groups), presenting equity concerns.Public preferences can also reflect invidious forces, and views of benefits often correspond to racial biases. 28To counteract these concerns, demographic differences in public opinion should also be of interest to policymakers.Even when policymakers are responding to reasons separate from public preferences (eg, political strategy and budget constraints), understanding the nuances of public opinion matters.or retired (n = 178).
b For responses to the question "In politics today, do you consider yourself…," individuals choosing Independent (n = 120), something else (n = 60), or don't know or refused (n = 13) were excluded from these analyses.
c Percentages are weighted to resemble the adult population of Kentucky residents.

Table 1 .
Demographic Characteristics, by Percentages of Medicaid Enrollees vs Nonenrollees (continued) a Percentages are weighted to resemble adult population of Kentucky residents.b

Table 2 .
Public Views on Medicaid Work Requirements and Mandatory Premiums in Kentucky Views of Medicaid Policy, by Medicaid Enrollment about whether Medicaid reduces enrollees' interest in working differed with marginal statistical significance, with Democratic enrollees less likely to agree and more likely to be neutral compared with Republican enrollees.Enrollees' beliefs did not differ by employment status, except for the belief that "Medicaid should only be for people who cannot work," which was endorsed by more employed enrollees compared with unemployed enrollees.

Table 2 .
Views of Medicaid Policy, by Medicaid Enrollment (continued) Percentages are weighted to resemble the adult population of Kentucky residents.

Table 3 .
Views of Medicaid Policy Among Medicaid Enrollees, by Employment and Political Affiliation However, this view may coincide with other beliefs not measured here (eg, that employers should provide affordable health insurance that makes Medicaid unnecessary).Our findings suggest that survey participants who support work requirements and premiums for Medicaid, in general, may not support specific policy features, such as terminating benefits for people who do not comply.People may envision and prefer enforcement mechanisms that do not affect benefits eligibility.They may also prefer smaller quotas than the 20-hour weekly threshold that has been repeatedly proposed.

Table 3 .
Views of Medicaid Policy Among Medicaid Enrollees, by Employment and Political Affiliation (continued) Excludes individuals not enrolled in Medicaid who reported being disabled (n = 46) a . Views of Work Requirement Policy by Medicaid Enrollment, Employment, and Political Affiliation